Postintubation tracheal stenosis provides a fundamental insight for clinical practice. During the patient’s preoperative preparation and throughout the surgical intervention, a multidisciplinary approach is employed. This approach incorporates a variety of surgical techniques concerning the following: trachea: addressing posttraumatic, postintubation, and iatrogenic complications; thyroid gland: addressing normal and pathological conditions; and proximal mediastinum and the nerve-vessel bundle of the neck.‌^[1] Postintubation stenosis is induced by the intubation tube’s balloon mechanical pressure and ischemic tracheal damage, tracheal injury from a placed tracheostomy cannula with an inflated balloon, or a combination of both. It manifests clinically with stridor or unexplainable dyspnea after a period of mechanical ventilation. Most patients with this type of injury are candidates for tracheal resection and reconstruction.^[2] The expected resection length is the most important determinative factor for the stenotic section’s resectability. The good surgical treatment principles require precise preoperative bronchoscopy assessment, full mobilization of the trachea intraoperatively, protection of both laryngeal recurrent nerves, precise anastomosis, and a motive regime by restricting the neck extension postoperatively.^[3]

This case presents the clinical management of postintubation tracheal stenosis, emphasizing the surgical approach and the positive outcome achieved through a complex tracheal resection and anastomosis procedure.

S. A. was admitted to the Thoracic Surgery Department at Kaspela University Hospital in Plovdiv with respiratory complaints. The patient reported stridor and dyspnea after 10 days in hospital on mechanical ventilation due to aspiration pneumonia. The family of the patient reported his systematic alcohol abuse. There was no family history of exposure to harmful factors or previous surgical interventions.

The computed-axial tomography recorded unequally thickened tracheal walls distally to the cricoid cartilage ventral up to 0.8 cm with lumen stenosis up to 0.7 cm transversely by an extent of 2 cm(Figs 1, 2).

A hyperplastic multilayered flat epithelium was observed in the histopathological study of tissue taken via clip biopsy during video bronchoscopy from the stenotic area. Following all investigations and the multidisciplinary clinical council discussion, it was decided that the presented pathology should be treated surgically.

Under general anesthesia with an intubation tube No. 5 (as a larger size could not be passed through), after the operative field had been carefully cleaned, a Kocher’s cervicotomy incision was made. The trachea was reached layer by layer. The isthmus of the thyroid gland was cut between two ligatures. This was followed by a circular tracheal disengagement around 6 cm distal to the thyroid cartilage. Intraoperatively, video bronchoscopy was done by pulling out the intubation tube above the stenosis, and marking of the exact stenotic tracheal section location was performed(Fig. 3). Circular resection of the stenotic section (2.5 cm). Reintubation via intubation tube No. 7. Positioning in the distal tracheal end. Termino-terminal anastomosis with one-layer catgut 3/0 prolene followed. Careful hemostasis. Hydraulic examination—no air-losing data. Flexible bronchoscopy surgery (FBS) repeatedly for anastomosis examination and repositioning of the intubation tube(Fig. 3). Two contact drainages were placed. Suture the operative wound layer by layer. Two skin sutures of 2/0 Vicryl were placed on the mandible’s angle and parasternal on both sides to avoid neck extension. (Figs 4, 5) .

Postoperatively, the patient was transferred to the anesthesiology and intensive care department on mechanical ventilation, hemodynamically stable without catecholamine support. Extubated on the first postoperative day. Calm operative wound, without active bleeding data from the drainages. The last ones were removed on the first postoperative day, and the patient was transferred to the thoracic surgery department. On the fourth postoperative day, control VBS for anastomosis assessment has been done. The same has been seen as intact without granulation or lumen narrowing data(Fig. 6). On the seventh postoperative day, both sutures for limiting the head movements have been removed.

Prior to being discharged from the hospital, a control computed-axial tomography of the thorax was performed. This imaging revealed that the anastomosis was intact and that the tracheal lumen was within normal parameters(Figs 7, 8) .

Histological investigation of the permanent hyperplastic multilayer flat epithelium. The patient was discharged in satisfying general condition.

Postintubation tracheal stenosis continues to present a serious surgical problem and a challenge for thoracic surgeons. The safety resection limit between 4 and 4.5 cm is narrow, and it requires exclusive precision and excellent mastery of multiple surgical techniques as well as many years of experience in tracheal surgery, as shown by Karapolat et al. In the study, several tracheal resections with end-to-end anastomosis had been performed, with the length of stenosis being from 2 to 4 cm.^[4] The disengagement of the larynx usually leads to 1 cm–1.5 cm added length (it is required by around 4% of the patients), as seen in a study by Allen et al.^[5] The performance of a control bronchoscopy on the 4th and 7th postoperative days is still the gold standard for anastomosis valuation.^[6] It allows the investigation of unsuspected problems and their prompt eradication. With some patients developing granulations and/or necrosis on the anastomosis, an effective method (of choice) is the use of video-assisted bronchoscopy with photocoagulation or rigid bronchoscopy under general anesthesia, as demonstrated in a study published by Spittle et al.^[7] The reintubation after such a surgery is usually a sign of poor surgical techniques and anastomosis performance, while sometimes it can be a necessity due to vocal cord or anastomosis edema that occurred, depending on the degree of obstruction, which can be graded by several proposed classifications, like the one suggested by Freitag et al.^[8] Reintubation in general is related to a worse prognosis. The stenotic segment’s resection and the performance of a termino-terminal anastomosis remain the preferred operative method. The subglottic stenoses present a true challenge and predispose to allowing more mistakes—bad anastomosis technique and worse results. In case of an unsuccessful first resection, it is needed to wait 3-6 months before a repeated operation, and the purpose is to get the inflammatory process under control. Repeated FBS and dilation are preferred methods for providing stable airways.^[9] The most common concomitant diseases that are presented by patients with postintubation tracheal stenosis are diabetes, obesity, and COPD (the decreased lung compliance requires higher ventilation pressure).^[10] The increased frequency of tracheal stenosis in women is due to an estrogen-induced increase of the transformation growth factors and precipitation of collagen types 1 and 3, which leads to fibrosis.^[11] Tracheal stenoses increased in frequency after intubation during the COVID-19 pandemic due to the long-term ventilation. It gets worse from the theory that the repeated cycles of ventilation on someone’s abdomen (prone position) can increase the intraluminal tube’s pressure in the anterior or posterior part of the glottis, increasing the stenosis formation risk.^[12,13] Many of these patients with COVID-19 with postintubation tracheal stenosis are shown with late symptoms after discharge from the ICU, and that is the reason a purposeful evaluation for excluding postintubation tracheal stenosis is recommended. In the case of the right patient’s selection, good perioperative preparation, and thorough discussion from multidisciplinary teams, the success rate is over 90%.^[14] The most common complication after tracheal resection and anastomosis is suture line granulations, which have almost vanished with the use of absorbable sutures, as reported in a study by Grillo including 503 patients.^[11,15]

Effective management of postintubation tracheal stenosis hinges on early diagnosis, precise imaging, and a multidisciplinary surgical approach. This case demonstrates that meticulous planning and expertise in tracheal surgery can achieve excellent outcomes, restoring airway function and quality of life. Ongoing postoperative monitoring ensures sustained recovery, reinforcing the value of a systematic, patient-centered strategy. Achieving reliable outcomes in the treatment of postintubation tracheal stenosis requires meticulous patient selection, comprehensive preoperative evaluation, and careful preparation. As demonstrated in the clinical case reported, adherence to fundamental principles of tracheal surgery—first outlined over five decades ago—remains critical. In addition to this foundational knowledge, the surgeon’s proficiency in a broad range of specialized techniques directly influences surgical success and patient recovery. Timely and accurate diagnosis, effective multidisciplinary collaboration, and consistent postoperative monitoring were also key elements contributing to the favorable outcome in our case. These findings are well-supported by current medical literature, which consistently emphasizes the importance of a systematic and collaborative approach in managing this complex condition.